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Herpes vegetans of the vulva

      A 40-year-old woman sought a consultation for a 3-month history of a vulvar tumor. She had a history of HIV infection with unregular therapeutic compliance. Physical examination revealed an exophytic, fleshy yet hard, ulcerated mass located in the inferior third of the left labia majora (Figure 1). Adjacent condyloma were observed. Histologic examination depicted a pseudoepitheliomatous hyperplasia next to an ulcerated epidermis, associated with an inflammatory infiltrate (including plasma cells, neutrophils, and eosinophils) and cytopathic changes (Figures 2 and 3). These findings were suggestive of a herpetic infection, ruling out a malignant origin. Immunochemistry showed nuclear positivity for herpes simplex virus II (HSV-II) (Figure 3). Furthermore, DNA for HSV-II was found in the biopsy using the polymerase chain reaction test. A diagnosis of herpes vegetans of the vulva was made, an infrequent cutaneous form of HSV infection that affects patients with congenital or acquired immunodeficiency. It often demands combined therapy to achieve complete resolution and to avoid recurrence, with the options being systemic antivirals, topical immunomodulators, and surgery.
      Figure thumbnail gr1
      Figure 1Exophytic, well-circumscribed vulvar mass showing superficial ulceration
      Abril-Pérez. Herpes vegetans of the vulva. Am J Obstet Gynecol 2021.
      Figure thumbnail gr2
      Figure 2Epidermal pseudoepitheliomatous hyperplasia next to an extensive ulceration
      A dense inflammatory infiltrate can be advised along the entire dermis.
      Abril-Pérez. Herpes vegetans of the vulva. Am J Obstet Gynecol 2021.
      Figure thumbnail gr3
      Figure 3Cytopathic changes and immunochemistry for HSV-II
      A, The cytopathic changes include swollen keratinocytes and multinucleated cells with molded nuclei and margination of the chromatin (arrowheads). B and C, Positive immunochemistry for HSV-II.
      HSV-II, herpes simplex virus II.
      Abril-Pérez. Herpes vegetans of the vulva. Am J Obstet Gynecol 2021.
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